Insurance Sup Application Form

INSURANCE SUP APPLICATION FORM

Use this form to provide supplemental underwriting information necessary to evaluate, bind, or amend insurance coverage. The information provided becomes part of the insurance application and is subject to review for accuracy and completeness. Failure to disclose material facts may result in denial of coverage or rescission of the policy.

Applicant / Insured Information

Individual Corporation LLC Trust

Policy Details

Homeowners Auto General Liability Commercial Property Professional Liability Other:

Policy Period: From to . Requested effective date: .

Supplemental Coverages

Select supplemental coverages requested or to be reviewed by underwriting:

Earthquake Flood Rental Reimbursement Personal Property Replacement Cost

Umbrella / Excess Liability Medical Payments Legal Defense Costs Uninsured/Underinsured Motorist

Prior Insurance & Loss History

Prior Policy Period: From to .

Have there been any claims, losses, or incidents in the past five (5) years? Yes No

Insured Property / Item Details (if applicable)

Beneficiary Designation (Life / Payouts where applicable)

Exclusions & Limitations

The following exclusions are commonly applied to supplemental coverages. This list is non-exhaustive. Underwriting may impose additional exclusions or limitations as a condition of issuance.

• Losses resulting from intentional acts, fraudulent acts, or willful misconduct by any insured.
• Normal wear and tear, gradual deterioration, mechanical breakdown, and latent defects.
• Damage arising from acts of war, nuclear hazard, or government seizure unless specifically endorsed.
• Pollution, contamination, and mold unless a specific endorsement is procured.

Applicant acknowledges review of typical exclusions and agrees to accept additional underwriting exclusions if required. I acknowledge and understand these limitations.

Required Documentation (attach as applicable)

Please indicate which documents are attached with this supplemental application:

Proof of Identity Photographs of Insured Property Prior Policy Declarations Inventory / Valuation Reports

Declarations, Authorizations, and Certification

The undersigned represents and warrants that all statements contained in this supplemental application are true, complete and correctly recorded to the best of the undersigned's knowledge. The undersigned understands that these statements form the basis for underwriting and issuance of the policy, and that material misrepresentation or omission may result in denial of coverage, rescission of the policy, or adjustment of terms and premiums.

The undersigned authorizes the insurer, its representatives and authorized service providers to obtain and share underwriting and claim-related information, including prior loss history and credit-related information where permitted by law, for the purpose of evaluating this application and administering the policy. The undersigned further authorizes reasonable inspections of property described herein and agrees to cooperate in any investigation of claims.

The insurer's obligation to provide coverage is subject to acceptance by the insurer and issuance of a policy or endorsement. Coverage shall not be bound unless and until a binder or policy is issued by the insurer. Any quoted premium is an estimate and may be adjusted based on underwriting review.

Fraud Warning: Where permitted by law, intentional false statements or omissions made with the intent to defraud, or that materially misrepresent pertinent facts, may be a criminal offense and may lead to civil liability, denial of benefits, or policy cancellation.

By signing below, the applicant certifies under penalty of perjury that the information contained in this supplemental application is true and complete, and that the applicant has the authority to provide the information and execute this application on behalf of any named insured.

Additional Information / Remarks

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